With the improvements in neonatal intensive care and recognition of the hazards in transporting high- risk neonates to the operating rooms, surgical intervention in the neonatal intensive care unit (NICU) has become routine practice. While some complications have been thought to be similar, patient safety, associated with high-risk operations in the NICU, has never been rigorously studied. This may be the result of the lack of definition and standardization of error and adverse events as it relates to neonatal surgery. Surgery and neonatal intensive care units are major contributors to medical errors and adverse events. The error rate among surgical patients have been demonstrated to be two to four times of those estimated in the Institute of Medicine report, with approximately 30% contributing to surgical deaths. Nearly half of adverse events are related to surgery. Due to this disproportionate number of events related to surgery, several interventions have been proposed to increase patient safety including improving the quality or teamwork in the operating rooms. However, the type and incidence of errors and adverse events due to off-site surgery, such as in the NICU, is unknown. The purpose of this project is to determine type and incidence of errors and adverse events associated with neonatal surgery performed in the NICU. The primary hypothesis of this project is that errors and adverse events in the setting of neonatal surgery performed in the NICU are underestimated and inaccurately identified with current reporting systems. Specific Aim 1: To prospectively determine the type and incidence of errors and adverse events in neonatal surgery performed in the NICU. Specific Aim 2: To develop an errors and adverse events reporting tool for neonatal surgery in the NICU. Specific Aim 3: To validate the NICU surgery-specific errors and adverse events reporting tool in a pilot observational trial. PUBLIC HEALTH RELEVANCE: Neonatal surgery performed in the neonatal intensive care unit (NICU) is a complex, high-risk surgical endeavor. A specialty-specific reporting tool that identifies near misses, errors, and adverse events for NICU operations would establish a framework for reliable surveillance. Quality improvement initiatives in the surgery and NICU could utilize the tool to measure effectiveness of the intervention.